Inspection on 07/07/05 for Pembroke Rest Home

This inspection was carried out on 7th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pembroke Rest Home 12/07/07

Pembroke Rest Home 17/07/06

Pembroke Rest Home 07/11/05

Pembroke Rest Home 07/02/05

Pembroke Rest Home 08/07/04

Pembroke Rest Home 06/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Pembroke Rest Home 2 Pembroke Avenue Walkergate Newcastle upon Tyne NE6 4QU Lead Inspector Deborah Haugh Announced 7 & 8 July 2005 10.30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pembroke Rest Home Address 2 Pembroke Avenue Walkergate Newcastle upon Tyne NE6 4QU 0191 224 0862 0191 224 5803 n/a Mrs Jennifer Houghton Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Irene Louise Smith CRH 21 Category(ies) of DE(E) Dementia - over 65 (6) registration, with number OP Old Age (15) of places Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 7/2/05 Brief Description of the Service: Pembroke House provides care and support for 21 older people who require residential care. Six of the 21 places available are specialist beds for older people with dementia care needs. The Home is situated in a residential area of Walkergate. The accommodation is spread over two floors and offers the following facilities – nineteen single bedrooms, including two with en-suite, and a double bedroom; a central kitchen and laundry; a large lounge and a dining area; a conservatory. A pleasant garden area is available to the side of the building and there is a yard to the rear of the Home.The Home has good access to local facilities and transport systems. On-road parking is available to the front of the building. Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This un-announced inspection took place over 2 days and was in response to an anonymous complaint. The complaint was regarding care received by service users. There were 16 service users at the home. Service users and staff shared their views about the home. Time was also spent observing the contact between service users and staff. Three Care Plans for service users care were examined. The home’s Accident Record, menus and communication systems were checked. Staffing numbers were satisfactory on both days. What the service does well: What has improved since the last inspection? What they could do better: The management of the home must improve so that service users are protected from harm and their health and safety is promoted. The Manager and her staff must have training in nutrition, dealing with behaviours which challenge the home and aggression. Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 6 The Registered Manager and Registered Provider must improve the care plans, records of care given, nutritional diets and reviews of care. Management follow up of incidents such as aggression must happen and where necessary involve professional help. Vacuuming during meal times disturbs the service users and may affect their motivation to eat. The Manager agreed to stop this practice. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None assessed EVIDENCE: Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 & 8 Care plans do not cover all the needs of service users and interventions do not consistently guide the practice of staff. Recording systems do not consistently demonstrate the care provided to service users. Service users do not consistently receive the health and psychological care they need. EVIDENCE: Three care plans for service users care were not in enough detail to guide the practice of staff particular in regard to nutrition, behaviours which challenge the home and responding to aggression. Assessments are completed but interventions to address needs are not in place. Records of care given are not in detail or helpful in the care plans. Annual reviews had not been held since 2002 for the three service users. Records indicated that the health care needs of one service user had not been investigated. Following the inspection the Manager investigated the concerns. Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 10 The home records confidential information about service users in a Staff Handover. This is not good practice. After the inspection the Operations Manager and Manager said this was against Company Policy and would now stop. Staff demonstrated that they know the resident’s needs and wishes and have good relationships. Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 Dietary needs of service users are not catered for and care plans do not provide special dietary guidance for care staff or the chef. Service users do not dine in a relaxed and congenial setting. EVIDENCE: During the two days of the inspection the lunchtime arrangements were observed. The lounge is vacuumed during the meal, which is the same room as the dining room. The noise is distracting and staff found it hard to communicate with service users. They had to shout. Service users were unable to be heard or communicate with each other. The Manager agreed to cease the practice of vacuuming during meals. Both lunch meals looked appetising and smelt good. Staff encouraged service users to eat their meals. A senior staff nurse visiting the home confirmed that she had heard and seen staff encourage service users to eat and they would sit with service users if needed. The 4-week menus do not offer 2 portions of fruit or dairy items consistently. Butter, which has better calorific benefit than margarine is not available and following the inspection was purchased. Drinks and snacks are not identified Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 12 on the menu. Vegetables are not itemised but are recorded as ‘seasonal vegetables’ . Fillings of sandwiches and flavour of soup are not recorded. The chef demonstrated his knowledge of special diets. Care plans do not contain sufficient detail to guide the practice of staff regarding nutritional needs. Records do not demonstrate what diet service users who require special diets have received. The Manager and staff have not received training in nutrition. The Company informed CSCI that menus are being reviewed and they are arranging training. Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Management arrangements for the protecting service users are not satisfactory placing them at risk of harm. EVIDENCE: Care notes indicate that professional help has not been sought for episodes of aggression from service users towards service users and staff. Behaviour Incident forms have not been completed. There is no evidence of management follow up regarding these incidents or specific guidance to deal with incidents of aggression in care plans. An Immediate Requirement was given for incidents to be addressed. The Manager and her staff are currently completing Protection of Vulnerable Adults Training. Staff confirmed that they would report any concerns to the Company or the Manager. Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 26 The areas inspected in the home were clean and safe. EVIDENCE: A brief tour of the home occurred which included the kitchen, laundry, communal areas and three bedrooms. The home was clean and safe. Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 30 Staffing numbers are appropriate to the assessed needs of the residents, size and layout and purpose of the home at all times. Care staff do not have sufficient knowledge regarding nutrition, dealing with behaviours which challenge the home or aggression EVIDENCE: The home maintains the level of staffing in accordance with previous agreements with the local authority and this reflects the size and layout of the building and the needs of the residents currently living in the home. The current levels of staffing are Staffing Levels 19 residents 21 residents AM 3 4 PM 3 3 EV. 3 3 WAKING NIGHTS 2 2 The chef demonstrated his knowledge of nutritional needs of older people and special diets and has received training. However the Manager and her staff have not had nutritional training but the Company confirmed that they are planning to provide this. The Manager and Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 16 her staff also require training when dealing with behaviours which challenge the home, and aggression. The Manager and her staff are currently completing Protection of Vulnerable Adults Training. Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32, 37 & 36 The Manager is not providing clear leadership and supervision. The Manager does not have sufficient knowledge regarding nutrition, dealing with behaviours which challenge the home or aggression to protect service users. Management do not ensure that service users health, safety and welfare are promoted. EVIDENCE: Staff described the Manager as approachable and said that she listened to concerns. Staff are unfamiliar with the term Supervision and did not receive supervision on a 1:1 basis 6 times a year. The Manager said she was still catching up with supervisions. Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 18 The home records confidential information about service users in a Staff Handover. This is not good practice. Records indicate that the Manager is not providing adequate oversight of care plans, recordings, incidents of potential harm and is not involving other professionals regarding nutrition, incidents of aggression and health concerns. CSCI have previously raised concerns regarding the extra duty cover which the Manager covers. The Company had agreed two full days given over to completing the necessary management tasks in addition to a further two hours five days a week. However the Manager has continued to cover extra duties. Following the inspection a meeting was held with the Operations Manager and Manager. The Company has recruited a Deputy Manager who will provide more support for the Manager by the Company as well as continued Area Manager support. Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 1 COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 1 1 1 x x x 1 1 x Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 8 & 15 Regulation 15(2) & 16(2)(i) Requirement Service Users must receive appropriate diets and nutritional supplements based on nutritional screening assessments and good nutritional practice. Nutritional interventions and outcomes in care plans must be in sufficient detail as stated in Nutritional Screening Tool Assessment guidance interventions and good nutritional practice. Where nutritional risks are identified care plan records must be maintained and kept under review to provide detail of the intervention and as a means of evaluating action in order to highlight possible further intervention eg involvement of other professionals Confidential information must not be recorded in the Staff Handover Book. Reviews must be held regarding the care which service users receive and involve the service user and/or their representatives. Records of food provided to service users must be in Timescale for action 31/7/05 2. 7,8 & 15 14(2) & 15(2) 31/7/05 3. 7,8 & 15 14(2) & 15(2) 31/7/05 4. 5. 37 7 17 15(2) 18/7/05 31/8/05 6. 15 16(2) & Schedule 31/7/05 Page 21 Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 4 7. 37 37 8. 7,8 &18 13(6) & 15(2) 9. 18 13(6) 10. 36 18(2) 11. 8 12 12. 30 10(3) & 18(2) sufficient detail to determine whether the diet is satisfactory and service users must receive adequate quantities of nutritious food. (offer 2 portions of fruit a day, provide 2 dairy items, use butter to build calorific value, provide detail of snacks and drinks, provide 2 vegetables and detail fillings of sandwiches and flavour of soup.) Events which affect the welfare of service users must be notified without delay to CSCI. Immediate Requirement Service users behaviours which challenge the home or incidents of aggression must be recorded using agreed proforma. There must be management follow up involving other professionals as appropriate. Care plans must identify strategies for dealing with incidents. Immediate Requirement Care Managers must be contacted in view of possible Protection of Vulnerable Adults Procedures being invoked. Immediate Requirement Staff must receive 1:1 supervision in line with NMS agreed timescales (6 times a year) Service users health needs must be dealt with immediately following discovery. Immediate Requirement The Manager & staff must receive training in Nutrition for Older People and special diets and dealing with behaviours which challenge the home or aggression. 8/705 18/7/05 18/7/05 31/8/05 15/7/05 30/9/05 Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 15 Good Practice Recommendations Cease the practice of vacuuming during mealtimes so to ensure a suitable atmosphere conducive to eating and enjoying food. Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Northumbria House Manor Walks Cramlington, Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pembroke Rest Home B53-B03 S451 Pembroke V224267 070705 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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